PD: Cardiac Sounds

9/3/25

S3

rapid PASSIVE filling of blood from atrium → ventricles (like leaving a classroom after class is done)

• heard in early diastole after s2

• quiet, low-pitched song. heard at apex and along left sternal border with bell

• best heard in left lateral decubitus position

blood is rushing in (Think of prof rushing out the door, but then it comes to a complete halt like it bangs into a student/wall)

can be normal

S3 causes

• normal physiologic finding in patients <30 yrs/old (related to rapid ventricular filling)

• CHF (systolic)

• constrictive pericarditis

• hypertension

S4

Caused by the atria squeezing blood quickly into a stiff ventricle that doesn’t stretch well

• similar to S3 heart sound (where blood hits ventricle) but in THIS case, it happens later in diastole

• normally in early diastole, ventricles fill passively with blood. at the end of diastole, atria contracts to push in a bit of blood

  • however, if the ventricle is non-compliant (stiff), this forceful filling causes a sound that can be heard before S1 (in late diastole)

• PATHOLOGIC - ventricles aren’t working right

  • also heard pretty well with left lateral recubitus

S4 causes

• pts with stiffened left ventricle

• chronic hypertension

• aortic stenosis

• cardiomyopathy

• acute MI

• rupture of chordae tendineae in acute mitral regurgitation

• associated with diastolic heart failure

gallops

s3 (early to mid diastole)

• kenTUCKy (y is gallop, stressed syllable is S2)

• (s1-s2-s3)

s4 (late diastole)

• tennessEE

• (s4-s1-s2)

  • ten sound is the gallop, stressed syllable is s2

s3 and s4

• missisSIPpi

• (s4-s1-s2-s3)

  • “Mis” is s4, “pi” is s3, stressed syllable is S2

(extra sounds heard in diastole)

special test for s3/s4

• left lateral decubitus

  • listen with bell with patient lying in LLD over 5th ICS in MCL and 5th ICS in MAL to evaluate for mitral murmurs

left decubitus position

good for s3 and s4 and mitral murmurs, esp mitral stenosis

s1

closure of AV valves (mitral and tricuspid)

• associated with systole, blood is being ejected from ventricles

S4

pathologic. associated with chronic HTN, ventricular stiffness, acute MI. occurs late in diastole

s2

closure of the semilunar valves (aortic and pulmonic)

• associated with diastole

s3

this can be normal (young, athlete, pregnant patients) or associated with CHF

• happens early diastole

murmurs

• swooshing or blowing sounds caused by

  • forward flow through a stenotic (narrowed) valve

  • backward flow through valve that fails to close (insufficiency)

  • increased flow through a normal valve

characteristics: timing, loudness, pitch, pattern, quality, location, radiation, posture

(location is very important! and timing)

innocent murmur

occurring in individual WITHOUT anatomic or physiologic abnormality

functional murmur

occurs in individuals with no anatomic cardiac defect but with physiologic abnormality such as anemia

organic murmur

occurring in individuals with a cardiac defect with or without a physiologic abnormality

murmur characteristics

location

• anatomic location where you can best hear it

timing

• systole vs. diastole

  • systole: pulse (S1)

character

• crescendo-decrescendo, holo-systolic, crescendo

stenosis

outflow obstruction

regurgitation (insufficiency)

inadequate closure of valves

systolic murmurs

between s1 and s2

diastolic murmur

between s2 and s1

systolic ejection murmur

begin after the 1st heart sound, attains a peak during mid-systole and terminate before the 2nd heart sound

pan-systolic murmur

during all of systole

pan-diastolic murmur

during all of diastole

pro-diastolic murmur

early diastolic

pre-systolic murmur

late diastolic

continuous murmur

continue through all of systole and all/part of diastole

grade I heart murmurs

heard only with concentration in quiet room

grade II heart murmurs

soft, low-intensity murmur

grade III heart murmurs

loud murmur (noticeable)

grade IV heart murmurs

loud murmur associated with palpable thrill

grade V heart murmurs

loudest murmur heard with stethoscope on chest wall

• has a palpable thrill

grade VI heart murmurs

murmur loud enough to hear with steth OFF/NEAR chest

note

usually if its more loud it’s worse UNLESS it’s SO bad you can barely hear when you normally can

• something a PCP can hear

but it really does depend on the type of murmur

aortic stenosis

2nd ICS right sternal border

character: injection, crescendo-decrescendo (gets louder as increase pressure goes. prof made example of how first person out door is easy, but then it gets crowded, then by the time you’re last, it’s easier to get out)

radiation: to carotids

• carotid pulse is delayed/weak

timing: systole

more common in the elderly

pulmonic stenosis/insufficiency

2nd ICS left sternal border

aortic regurgitation

3 ICS left sternal border

tricuspid stenosis/insufficiency

4 ICS left sternal border

mitral stenosis/insufficiency

5th ICS left MCL (mid clavicular line)

systolic mumurs

“AS MI TI PS”

• aortic stenosis

• mitral insufficiency

• tricuspid insufficiency

• pulmonic stenosis

systole: between S1 and S2

• s1 heard which represents CLOSURE of AV valves (so semilunar valves are open)

aortic stenosis

symptoms

• heart failure

• syncope

• angina (end stage-disease for symptoms)

common early symptoms

• asymptomatic

• dyspnea on exertion (one of the most common symptoms. related to diastolic dysfunction with increase in LV filing pressures w/ exercise and inability for LV to increase cardiac output with exercise)

• presyncope

• exertional angina

pulmonic stenosis

• **site: 2nd ICS LSB**

• character: crescendo-decrescendo

• radiation: left shoulder

• timing: systolic

due to enlargement of right ventricle, there can be associated lift to LSB

• can be associated with S2 splitting

more common in children/congenital defect (newborns: can be cyanosis// adults: can have no symptoms or if severe have symptoms)

• can be caused by complication of another illness (rheumatic fever or carcinoid syndrome)

signs + symptoms depends on severity (severe cases = heart failure like dyspnea, fatigue, syncope, CP, edema)

mitral insufficiency (regurgitation)

site: best heard at 5th iCS LMCL

character: holosystolic (all the way from S1→S2)

radiation: left axillary area

intensity: loud

pitch: high pitched

timing: systole

symptoms of mitral insufficiency (regurgitation)

symptoms

• asymptomatic

• symptoms tend to occur if there is eventual left ventricular cavity enlargement with systolic dysfunction, pulmonary hypertension, or development of A-fib

most common symptoms

• exertional dyspnea

• fatigue

• palpitations

mitral valve prolapse

• common cause of mitral regurgitation

  • MVP does not always have regurgitation

• examination: auscultation of non-ejection click

  • thought to be caused by mitral chordae snapping during systole

• diagnosed by imaging

  • billowing of mitral leaflet >2mm above annular plane

    • displacement into left atrium from disruption/elongation of leaflets, chordae, papillary muscles

causes of mitral valve deficiency

usually due to abnormality of valve apparatus (leaflet, chordae tendineae, papillary muscles and/or annulus)

• can also be secondary or function, related to another cardiac disease (coronary heart disease or cardiomyopathy)

prolapse

valve leaflets balloon upward as the ventricle contracts

regurgitation

valve leaflets do not properly close, forcing blood back into the atrium

mitral valve prolapse click

• pt performing Valsalva maneuver → dec preload and causes murmur/click to occur early in systole

• patient squatting = inc preload and inc left ventricular volume → murmur/click occur later in systole

tricuspid regurgitation/insufficiency

site: 4th ICS LSB

character: holosystolic

radiation: apex

timing: systolic

physical exam: pt can be cachectic, chronically il appearing, cyanotic peripheral vascular, JVD

Leads to significant venous congestion, especially of the liver and gut.

• Chronic congestion impairs nutrient absorption, reduces appetite, and causes wasting.

• Right-sided heart failure signs are usually much more prominent.

• Backflow of blood → GI stasis, edema, and even protein-losing enteropathy → cachexia.

tricuspid insufficiency

functional, related to tricuspid annular dilation and leaflet tethering in the setting of RV remodeling caused by pressure or volume overload (or both), myocardial infarction (MI), trauma

symptoms:

• asymptomatic

• symptoms occur when right atrial and venous pressures increase and can cause heart failure (fatigue, exertional dyspnea related to low cardiac output)

exam:

+JVD, more often diagnosed by exam of neck veins than by auscultation

Feature	Simplified Explanation
Cause	Right heart remodeling leads to tricuspid valve leaking
Triggering Conditions	RV pressure/volume overload, MI, trauma
Symptoms	Often none at first; later fatigue, shortness of breath
Exam Clue	Neck vein bulging (JVD) is a key sign
Why It Happens	Valve can't close due to stretched ring and tethered leaflets

pulmonic regurgitation (insufficiency)

site: 2nd ICS LSB

character: decrescendo

radiation: 3rd and 4th ICS LSB

timing: early diastolic

asymptomatic, can be common (high pressure → pulmonary HTN, low-pressure causes → dilated annulus, congenital abnormality of valve)

diastolic mumurs

1. aortic insufficiency/regurgitation

2. mitral stenosis

3. tricuspid stenosis

4. pulmonic insufficiency/regurgitation

seen diastole between S2 and S1

the AV valves should be open (b/c semilunar valves are closed)

pulmonic stenosis

is congenital, you would see as a child. the only one

right ventricle

tolerates a volume load better than high pressures, tends to tolerate low-pressure pulmonary valve regurgitation for long period of time without dysfunction

graham-steell murmur

If you have pulmonic hypertension, that causes lots of pressure on the valves, which leads to pulmonic insufficiency/regurg, and that backward sound of blood moving back = graham steel murmur

DIASTOLIC murmur

noted when pulmonic insufficiency occurs with pulmonary HTN, can only determine if you have ECHO

• high-pitched, blowing murmur beginning with accentuated S2

• decrescendo in nature

• may increase in intensity with inspiration

pulmonic insufficiency

often asymptomatic until development of RV dysfunction

• initial symptoms: exertional dyspnea, fatigue

• later: palpitations, lightheadedness

  • if severe, might be right sided heart failure (swelling in extremities)

aortic regurgitation

erb’s point!

site: 3rd ICS LSB

character: decrescendo

radiation: erb’s point and apex

timing: early diastolic

• often asymptomatic, in severe cases can have dyspnea, angina, heart failure

• dyspnea with exertion related to LV dysfunction

de musset’s sign

anterior-posterior bobbing movement of head synchronous with the arterial pulse (aortic regurgitation)

Increased stroke volume in AR causes the head to move with each heartbeat

corrigan pulse

abrupt distension and collapse in the carotid artery

• with inspection/palpatation of carotid artery, pulse is bounding

(aortic regurgitation)

A rapid, forceful upstroke (distension) followed by a quick, sudden collapse of the carotid pulse (Caused by increased pressure due to the blood going backward in aortic valves)

austin-flint murmur

• associated with aortic regurgitation and mitral stenosis

• regurgitant blood flow across aortic valve can cause functional mitral stenosis by impacting on the anterior leaflet of mitral valve and preventing it from fully opening in diastole

• low-pitched, mid to late diastolic murmur

• bell of steth 5th ICS LMCL and pct in left lateral decubitus

DIASTOLIC MURMUR

(nothing wrong with the mitral stenosis, so it’s more about the mitral leaflets. if you don’t have regurgitation, you would not have mitral stenosis)

mitral stenosis

• diastolic murmur

• activity with cause murmur to be louder (palpable 1st heart sound due to thickening of mitral valve leaflets)

  • activity will increase the amount of blood moving through heart

site: L 5th ICS MCL

character: MID-diastolic (may have opening snap)

radiation: apex to axillary line

timing: diastolic

remember decrescendo (when middle part of the classroom is trying to get out of the room)

• relating to thickening/immobility of leaflets resulting in obstruction of blood from LA → LV

• often caused by rheumatic involvement

mitral stenosis

when you ever hear something about diastolic with OPENING SNAP/CLICK! diastolic! radiates from apex to axillary line!

aortic stenosis

crescendo/decrensco

mitral or tricuspid insufficiency

holosystolic

symptoms of mitral stenosis

• exertional dyspnea

• decreased exercise tolerance

• fatigue

• hemoptysis (coughing up blood)

• chest pain

complications

• ascites

• lower extremity edema

• stroke

• a-fib

mitral stenosis

very rare

• elevated left atrial pressure and pulmonary venous hypertension causes reduced lung compliance and decrease in vital capacity

  • can be related to inability to increase cardiac output with increased metabolic demands

High pressure in the left atrium (heart chamber) backs up into the lungs.

This causes fluid buildup in the lungs.

Lungs become stiff and don’t expand easily (low compliance).

You can’t breathe in as deeply — so vital capacity (lung volume) goes down.

❤ Why it matters:

The heart can’t pump more blood during activity.

So you get tired and short of breath with exertion.

tricuspid stenosis

rare

• rheumatic in origin, more common in women

• does not occur by itself, associated with mitral stenosis

• symptoms: ASSOCIAED WITH but does not cause pulmonary congestion and fatigue, sometimes due to low-cardiac output

tricuspid stenosis

site: 4th ICS LSB

character: mid decrescendo

radiation: apex

timing: diastolic

must have a degree of suspicion, often overlooked

symptoms related to combo of obstruction through valve and elevated right atrial pressures

• fatigues, sometimes abdominal discomfort → cirrhosis, jaundice, etc

increase/decrease murmurs

changes to pre-load

• valsalva maneuver (dec preload)

• leg raise/squat (inc preload)

changes to after-load

• hand grip (inc afterload)

valsalva maneuver

forced expiration against a closed glottis which causes an increase in intrathoracic pressure

• dec venous return

• dec cardiac output

• inc arterial pressure

• effects heart rate (dec → inc)

snaps

(early diastolic “opening snap” - mitral stenosis

clicks

associated with valves - prosthetic valves

mid-systolic click

mitral valve prolapse

pericardial friction rub

rough scratchy sound heard best in inspiration

• esp with patient sitting up and leaning forward (not the same as the special ausculatory maneuver)

• best heard along left sternal border

systolic and diastolic component

creaking,crunching sounds